mydrfreeze.com - New Patient Paperwork (Adult Form)

Name:

First NameLast Name

Date:

Date

Email:

example@example.com

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Tel (C)

Please enter a valid phone number.Format: (000) 000-0000.

Tel (W)

Please enter a valid phone number.Format: (000) 000-0000.

Age:

Date of Birth:

Date

Gender:

Occupation:

Hours per week:

Live with:

Health Insurance name and address:

Policy Holder’s Name:

Relationship to policy holder

Group#:

Policy #:

Employer

How did you hear about our clinic?

Have any other family members been to our clinic:

Person to contact in case of emergency:

Relationship:

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Any person(s) you authorize us to share your medical information with

Are your currently receiving healthcare?

If yes, where and from whom?

What health concerns do you have today?

Any family history of the following: please check next to any the apply

Any Hospitalizations/ Surgery

When

When during the day is your energy the Best:

When during the day is your energy the Worst:

Please list any allergies to medications, food or environment:

Current Medications please list:

Rows	Current Medications
1
2
3
4
5
6

Supplements:

Main interests and hobbies

Do you exercise

How often

And what forms

How many hours do you sleep

Do you sleep well?

Any major traumas

History of abuse

Currently smoke

Past smoker

If so how many years

Weight lbs

Weight one year ago

Max weight

When

Height feet

Inches

Check next to any that apply

Mental/Emotional:

Endocrine:

Immune:

Vaccinations/Covid Vaccine which one:

Date

Any reactions;

Neurological:

Respiratory/Cardiovascular:

Skin:

Gastrointestinal:

How many bowel movements per day

Urinary:

Musculoskeletal:

Vascular:

For Women:

Menses

Age of onset

Last Menses

Flow

Heavy

Painful

Cycles Regular

How long does cycles last?

Other check all that apply

Birth control? - if so how long and type

# of Pregnancies:

Miscarriage:

Problems conceiving

Any additional information

For Men:

Any other information

We look forward to helping you reach optimal health and wellness in your life!

If you have any questions please do not hesitate to ask.
Your family at Freeze Wellness

Patient Name:

First NameLast Name

Age:

Date of Birth:

Date

Tel:

Welcome to Freeze Wellness and thank you for selecting us for your healthcare needs. We look forward to helping you along the way to great health.

Cancellation & Rescheduling Policy:
Your appointments are very important to us! They are reserved specifically for you. We respectfully request at least 2 business days for cancellations or rescheduling of your appointments.

Please understand that appointments that are missed, cancelled or changed without giving us enough notice, are missed opportunities for us to fill the apt time with clients that are on our waiting list.

Any appointment missed, cancelled or changed without 2 business days notice will result in a charge of 100% of your appointment fee. Please note you will receive several reminders via email and text prior to your apt date.

Please understand it is your responsibility to remember you appointment dates and times to prevent any missed appointment which result in the cancellation fee. Not receiving an electronic notification of your apt from us is not sufficient reason to miss an apt.

If you do need to cancel please either call the office at 623-824-9600 and leave a message if it goes to voice mail, or email us at admin@mydrfreeze.com.

All appointments must be held with a valid credit card at the time of booking. Your credit card information is stored with full encryption.

We do understand that emergencies can occur beyond your control. Please contact us and we will reschedule your existing appointment and no charges will apply.

Fees: Payment of all fees are due at time of the visit.

Insurance billing: We do NOT bill insurance, nor do we take any insurance plans. If you wish to submit a HICFFA form for possible reimbursement to your insurance carrier please let us know at the time of your visit.

This form can be sent in to the address on the back of your insurance card. Please note we do NOT give forms for Medicare.

Terms: All of our fees are subject to change without prior notice. Past due balances are subject to a 2% fee per month (18% annum) service charge, plus a monthly billing of $20.

Statement: I have read and understand the above policies of Freeze Wellness and agree with them. I consent to the treatment with Dr. Karen Freeze and accept full responsibilities for all expenses incurred on my account for visits, tests, or supplements, medications, etc.

In the event of non-payment, I will bear the cost of collection and/or all court costs and legal fees should it be required.

I authorize the release of any medical information necessary to process an insurance claim and authorize payment directly to the signed physician. Due to the new privacy policies this form must be signed to disclose your private health information. A copy will be provided to you on request.

Signature of patient and/or guardian

Date:

Date

Summary of Notice of Privacy Practices

We strongly believe in maintaining the confidentiality of personal information we possess and/or receive about you and are committed to protecting your privacy.

We do not disclose any non-public information about you to anyone, except as permitted or required by law.

We do not sell or otherwise disclose personal information for purposes unrelated to our health practice.

We maintain physical and procedural safeguards that comply with federal and state regulations to protect information about you and from unauthorized disclosure.

We may disclose information we believe necessary to conduct our business as is legally required. You have the right to access, review, and correct all personal information collected.

Acknowledgment of Receipt of Notice Privacy Practices Summary

This document is to be signed by a person legally responsible for the patient’s medical decisions relative to the treatment situation.

I, Type a label , hereby acknowledge that Freeze Wellness will provide me with a copy if requested, of the Notice of Privacy Practice Summary that states how medical information may be used and disclosed.

Signature of Patient/Guardian:

Date:

Date

INFORMED CONSENT FOR PEPTIDE THERAPY I am executing this consent to confirm my discussion with my Medical Provider and my understanding of the risks, benefits, and alternatives to treatment with peptide therapy. The goal and possible benefits of this therapy is to try and prevent, reduce or control the dysfunction associated with the aging process, through hormonal, balancing, control of oxidative stress, and other clinically significant therapeutic agents.

However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, off label, experimental, and unnecessary by the food and drug administration. (“FDA”) By signing this form, I understand the possible risks associated with this treatment.

Adverse reactions can Include, but not be limited to, injection site redness and transient high blood sugar. These side effects are dose related and usually eliminated by adjusting the dosage. I understand that my treatment will be recommended in an effort to prevent any side effects, but it cannot be guaranteed that I will not experience any side effects or adverse reactions. I understand that, as with any health treatment, there is no guarantee that I will receive the results I would like.

I understand the use of this treatment does not preclude me from using other treatments as well, though I recognize that I should inform any other medical practitioners I am seeing about the various treatments I am using. Note: Do not sign this form unless you have read it and feel that you understand it.

Ask any questions you might have before signing this form. Do not sign this form if you have taken medications, which may impair your mental abilities or if you feel rushed or under pressure. Peptide therapy is always optional.

I certify that I have read the foregoing informed consent, discussed the issues noted above, and had opportunities to ask questions and agree freely and voluntarily and accept all the terms above.

Client Name:

Client Signature:

Date

I have explained this informed consent and answered all questions and informed the patient of the available alternatives and the potential risks. To the best of my knowledge, the patient has been adequately informed and has consented.

Witness Signature:

Date:

Date

WELCOME TO FREEZE WELLNESS

Habits:

Terms of Agreement